Registered Nurse; RN Case Manager - MediGold remote

Employment Type: Full time Shift: Day Shift Description: Please note position is 100% remote, however colleagues who reside within a 50mile radius of Columbus, Ohio is required to come onsite 1x per quarter for quarterly meeting.

Medi Gold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

The RN Case Manager MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member’s family and other resources as appropriate. Assists in the implementation of Case Management software along with the Plan’s UM and QM Program and the review of the Plan’s Medical Management Plan.

• Education:
  
  Associate Degree in Nursing. Bachelor’s Degree as appropriate.
• Licensure / Certification: RN with current unrestricted state licensure required, nursing compact license is preferred. Ability to obtain licenses from other participating states
• Experience:
  
  Minimum of 5-7 years of clinical nursing experience with at least 2 years experience in utilization review, discharge planning, case management, or disease management experience required. Nursing experience in an HMO insurance company setting preferred.
• Demonstrated ability to analyze, summarize and concisely report medical utilization, and medical chart audit results.
• Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures.
• Conducts claim review as required for appropriate claims processing.
• Ability to implement and successfully utilize Case Management software.

• Coordinates with case management resources to assure development and documentation of a treatment plan for members who meet the Plan’s guidelines for Case Management and communicates the plan to the member’s PCP and other members of the care team.
• Completes an initial assessment of the member’s health status, including medical history, medications, symptoms, degree of support from family & friends, and current treatment prescribed by the member’s physician.
• Provide telephone follow up at the frequency agreed upon and teaching to promote goal attainment as well as providing educational materials appropriate for that member’s condition.
• Assist member to be an advocate for their healthcare and assist with formulating questions to ask the physician, as well as how to respond to common symptoms they might experience.
• Coordinates with the utilization review, case management, discharge planning staff within network facilities.
• Creates and maintains a case management database of referrals and treatment plans for Members.
• Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
• Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
• Conducts inpatient concurrent review.
• Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
• All other duties as assigned.

• Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers Daily Pay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and…